J Neurol Neurosurg Psychiatry:脑室外引流相关感染的危险因素

2018-03-22 杨中华 脑血管病及重症文献导读

脑室外引流(EVD)是最常见的神经外科手术。EVD相关感染(EVD-related infection,ERI)是一种严重并发症,增加死亡率和花费。文献报道,ERI发生率介于1 - 45%。发生率之所以有这么大的差异,主要原因是不同研究采用的ERI定义和研究方法不同所致。增加ERI风险的因素包括引流持续时间,CSF漏,频繁留取CSF以及潜在的病因。降低ERI风险的方法包括集束化EVD护理方案,围手

脑室外引流(EVD)是最常见的神经外科手术。EVD相关感染(EVD-related infection,ERI)是一种严重并发症,增加死亡率和花费。文献报道,ERI发生率介于1 - 45%。发生率之所以有这么大的差异,主要原因是不同研究采用的ERI定义和研究方法不同所致。增加ERI风险的因素包括引流持续时间,CSF漏,频繁留取CSF以及潜在的病因。降低ERI风险的方法包括集束化EVD护理方案,围手术期或持续给予预防抗生素,以及采用抗菌剂浸润导管(antimicrobial-impregnated catheters)。以前关于ERI的报道大部分为回顾性观察性研究,前瞻性研究往往都是神经外科单元(neurosurgical units,NSU)的单中心数据。这些研究具有明显的局限性。

2018年2月来自爱丁堡西部总医院的Western General Hospital等在JNNP上公布了他们的研究结果,他们前瞻性收集了多个NSU的数据,目的在于探讨英国和爱尔兰国家ERI发生率,验乞影响感染的关键因素。

英国和爱尔兰21家NSU参与了该研究,随访30天。纳入的患者为植入隧道式EVD导管的任何年龄段的患者,无CSF感染的证据。主要采集的数据包括人口学特征和手术参数,包括年龄、性别、潜在病因(underlying aetiology)、主要外科分级、导管类型(普通、抗生素浸润或含银导管)、隧道长度和脑脊液采集频率(每天一次、隔天一次、每周1-2次、不采样和不清楚)。主要终点为30天内ERI。

ERI定义为CSF培养阳性(和/或革兰氏涂片)或临床怀疑ERI(CSF细胞数增多血炎性markers升高以及感染的临床体征比如发热、假性脑膜炎和意识水平改变)。

在6个月期间,452例患者植入了495 EVD导管。平均随访30天,IQR 23 - 30天。EVD植入的原因:神经血管病导致脑积水站64.9%,肿瘤为17.8%,创伤为7.1%。大部分(98.6%)在手术室植入EVD,剩下的(1.4%)在ICU。大部分患者(85.3%)麻醉诱导时全身使用了预防性抗生素。留置引流管的持续时间平均为8天(IQR 4 -13天)。

随访期间46例诊断为ERI,30天感染率为9.3%。1例ERI患者数据丢失。剩下45例中,6例发生在拔除EVD后。平均的感染时间为9天(IQR 5-15天)。25例分离出29个病原体。最常见的病原菌为凝固酶隐形葡萄球菌(34.5%),其他依次为金黄色葡萄球菌(20.7%)和肠球菌(10.3%)。

抗生素治疗的平均时间为10天(IQR 7 - 14天)。感染者中77.8%置管时间>=8天,未感染者为47.3%(P<0.01)。同样,与未感染者相比感染者中CSF取样更加频繁(每天或隔天)(P < 0.01)。相反,感染者和未感染者导管类型(P = 0.31)、隧道长度(P = 0.71)和30天时永久性CSF分流(CSF diversion)(P = 0.91)没有显着性差异。

含银导管(silver-bearing catheters)感染率为13.7%,普通导管未7.5%,抗生素浸润导管为7.4%,但是没有达到显着性差异(P = 0.09)。从置管到感染的平均时间:抗生素浸润导管为11天,普通导管为8天,含银导管为7天。在感染者中,抗生素浸润导管使用抗生素治疗的持续时间为14天,含银导管为10天,普通导管为7.5天。

与每周1-2次CSF取样相比,每天和隔天取样者的感染风险明显增加。同样,与导管在<=7天时拔除者相比,导管留置超过8天这ERI风险更高(OR=2.54, 95% CI 1.14 to 5.7; p=0.02)。单变量分析显示,潜在疾病(underlying pathology)和感染风险无关(P = 0.76)。与导管隧道长度<=5cm相比,导管隧道长度超过5cm者ERI OR值为0.75(95% CI 0.3 to 1.45; p=0.29)。

在452例纳入到该研究的患者中,114例(25.2%)于置管30天内死亡。幸存者中,164例(48.5%)预后良好(mRS 0 - 2),174例(51.5%)预后不良(mRS 3-4)。

最终作者认为在英国和爱尔兰,研究期间ERI发生率为9.3%。EVD留置>=8天以及频繁CSF取样与较高感染风险有关。另外该研究还发现不同导管类型的ERI风险没有差异。

原始出处:

Jamjoom AAB,et al.Prospective, multicentre study of external ventricular drainage-related infections in the UK and Ireland.J Neurol Neurosurg Psychiatry. 2018 Feb;89(2):120-126.

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    2018-12-02 yinhl1978
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    2018-03-24 lsndxfj
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    2018-03-24 tastas